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Model Testing Application
Project Narrative
A. Description of the State Health Care Innovation Plan Testing Strategy
This proposal represents an opportunity for the State of Vermont to strengthen its
infrastructure and capacity to implement and evaluate health care payment and delivery
system reforms. Vermont’s State Health Care Innovation Plan includes a range of reforms that
are diverse in both scope and breadth and are based on evidence-based approaches to
achieving the three principle aims of the Affordable Care Act and Vermont’s Act 48: better care
for individuals, better health for populations, and better control of growth in health spending.
Vermont proposes testing how to balance incentives and drive delivery system change using a
range of population-based, collaborative, and individual-based reforms. Under the SIM grant,
Vermont’s payers (Medicaid and Commercial) will test three existing Medicare models: the
Shared Savings Accountable Care Organization, Bundled Payments and Pay-for-Performance.
By coordinating the testing and roll-out of these models across all payers and providers,
including both health and long term care providers, Vermont will be able to address many
limitations of previous reform pilots.
Vermont will leverage SIM funding to accelerate expansion and rigorous evaluation of these
models, particularly within the Medicaid and CHIP program. The models will maintain
beneficiary due process protections within Medicare, Medicaid and CHIP, and strive to improve
both access and quality. Findings will help not only Vermont’s long term strategy for reform
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but also add to the body of evidence on effective and scalable health reform across broader
payers and populations nationally.
Section B contains a detailed description of the three models being tested under the grant.
Figure 1 illustrates the model framework and how SIM grant funding will support their
implementation and evaluation as well as coordination with ongoing federal and state
programs and initiatives.
Figure 1. Vermont State Innovation Model Framework
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We anticipate the following timeline for implementation of these models:
Figure 2. Timeline for Vermont Testing Model and Related Activities
Governor Shumlin has delegated submission of this grant application to the Agency of Human
Services (AHS) and its Department of Vermont Health Access (DVHA). AHS is the Single State
Agency for Medicaid and it designates DVHA as the unit responsible for the operation of the
Vermont Medicaid Program. Medicaid programs for Vermont’s most vulnerable citizens
(former 1915(c)) and other optional state plan services are managed across the member
departments of AHS. In 2005, under an 1115 demonstration waiver and in state statute, DVHA
was authorized to operate the bulk of the state’s Medicaid program as if it were a managed
care entity. DVHA maintains Medicaid partnerships across state government through
interdepartmental agreements to operate the Medicaid program using the Medicaid managed
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care regulatory framework found in 42 CFR 438 et. seq. DVHA also houses the state’s Division of
Health Care Reform (including Health Information Technology planning) and the nationally
recognized Blueprint for Health Multi-Payer Advanced Primary Care model (MAPCP). In
addition, DVHA’s state appropriation includes the spending authority for the state’s second
1115 waiver, Choices for Care, operated by the Department of Aging and Independent Living.
Choices for Care provides consumers in need of long term services and support with full choice
between a home and community-based package of care or traditional nursing facility care. Both
these 1115 waivers are nationally recognized for the breadth and scope of innovations aimed at
improving access and quality of care while containing costs.
The Governor has directed DVHA to collaborate with the Green Mountain Care Board (GMCB)
in overseeing and implementing grant-supported activities. The GMCB is the state’s free-
standing health care regulatory agency, with responsibility for approval of hospital budgets,
small group and individual health insurance rates and certificates of need. The GMCB also has a
statutory responsibility to develop and implement multi-payer payment reform policy, moving
the state away from predominance of fee-for-service payments. It has the authority to
implement all-payer and all-provider rate-setting, has final authority on the state’s health
information technology plan, its health care workforce plan and the benefits to be offered in
the Health Benefit Exchange, and is charged with developing a “unified health care budget” for
the state. AHS, DVHA and the GMCB will carry out the activities proposed in this application
according to a mutually agreed-upon memorandum of understanding approved by the
Governor’s Office.
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1. Model Purpose
Vermont’s Act 48, passed in 2011, established an explicit state policy “to contain costs and to
provide, as a public good, comprehensive, affordable, high-quality, publicly financed health care
coverage for all Vermont residents in a seamless manner regardless of income, assets, health
status, or availability of other health coverage.” Vermont’s proposed testing models will
advance this goal. The three models we propose have four aims:
I. Increase both organizational coordination and financial alignment between Blueprint
advanced primary care practices and specialty care, including mental health and
substance abuse services, long term services and supports, and care for Vermonters living
with chronic conditions;
II. Implement and evaluate the impact of value-based payment methodologies that
encourage delivery system changes, improvements in care coordination and quality, and
better management of costs;
III. Coordinate a financing and delivery model for enhanced care management and new
service options for Vermonters dually-eligible for Medicare and Medicaid with additional
Medicare shared savings models, a Medicaid shared savings model and other models of
population-based payment being tested in Vermont; and,
IV. Accelerate development of a Learning Health System infrastructure, including: a reliable
repository for clinical and claims data populated by a statewide digital infrastructure;
statewide assessments of patient experience and team based services; ready access to
comparative reporting and modeling; teams of skilled facilitators to support
transformation; and an array of activities to support ongoing improvement. This
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infrastructure will be designed to meet the needs of providers engaged in delivery system
reform and the state’s needs for ongoing evaluation of the impact of reforms on health
care quality, costs, patient experience and population health.
The table below summarizes the unique purpose of each model.
Table 1. Testing Models
Population-based Performance Coordination-based Performance Provider-based Performance
VT Shared Savings ACO Models Bundled Payment Models P4P Models
To support an integrated delivery and
financing system for Vermonters through
an organized network of participating
providers who have agreed to align their
clinical and financial goals and incentives
to improve patient experience and quality
of care and reduce cost.
To remove FFS incentives and
replace with those which reward
collaboration and evidence-based
practices across specialties and
primary care providers for targeted
episodes or types of care which
represent opportunities for high
return on investment
To enable all payers,
particularly Medicaid, to use
P4P approaches to improve
performance and quality of its
health systems
2. Scope of the Models
The scope of the models, in terms of both service breadth and geographic coverage, varies.
Our intent is to scale up all successful models, in a coordinated fashion, to serve Medicare,
Medicaid and CHIP beneficiaries and commercially-insured Vermonters across the spectrum of
physical health, behavioral health (including mental health and substance abuse services) and
long-term services after the testing period. A variety of providers have expressed a willingness
to participate in the models, including regional physician-hospital collaboratives, statewide
networks and a statewide coalition of community health centers and federally-qualified health
clinics. The following table describes the expected scope of each of models to be tested:
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Table 2. Scope of Models
Population-based Performance Coordination-based Performance Provider-based
Performance
VT Shared Savings ACO Models Bundled Payment Models P4P Models
1. Medicare –Covers A & B costs for
Medicare beneficiaries attributed to
ACOs participating in Medicare’s
Shared Savings Program.
2. Medicaid—Covers all Medicaid costs
for Medicaid beneficiaries attributed to
ACOs participating in Medicaid’s
Shared Savings Program including
children covered under the CHIP
program who are often served in the
Blueprint's expanded pediatric medical
homes. This population also could
include the Medicare related costs of
dual eligible population if integrated
with the Financial Alignment initiative
for dual eligible beneficiaries.
3. Commercial—Covers all costs for
commercial beneficiaries attributed to
ACOs participating in commercial payer
Shared Savings Programs.
Vermont has several bundled payment
pilots under development, two of which
include Medicaid and Commercial payers:
1. Approximately 300 oncology patients in
St. Johnsbury health service area (HSA).
The scope of services to be included in the
pilot are primary care, specialty care and
hospital care for all patients who meet
pilot criteria and agree to participate in
the program.
2. Approximately 100 patients in the
southeastern areas of the state receiving
detoxification and additional services and
treatment in inpatient setting.
1. Medicare–Under its
value-based purchasing
program, Medicare is
phasing in P4P programs to
cover all providers (e.g. the
Hospital Value-based
Purchasing Program and
PQRS)
2. Medicaid—Building on
Medicare and commercial
payer efforts to expand
P4P to all providers serving
all Medicaid beneficiaries.
3. Commercial—
Commercial P4P programs
vary in scope and reach.
3. Description of the Models that Will be Tested
The three models to be tested are outlined in the table below. All closely mirror those being
tested by Medicare and are actively addressing limitations in previous pilots. In each case, the
models will help build provider capacity to report and act on performance data and better
manage population health and, in the case of shared savings and bundled payments, the
models will help prepare providers for more advanced forms of payment models that involve
performance accountability and financial risk.
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Table 3. Description of Models
Population-based Performance Coordination-based
Performance
Provider-based
Performance
VT Shared Savings ACO Models Bundled Payment Models P4P Models
Under this model, payers contract with provider-led
organizations who agree to take responsibility for the quality
and costs of care for a defined population. The model is meant
to increase accountability through sharing risk with providers
and provide positive financial incentives, in the form of shared
savings, for improving the organization and delivery of care.
There currently are two provider-led Medicare shared savings
accountable care organizations under development in Vermont.
• A Hospital-centric ACO: Fletcher Allen and Dartmouth-
Hitchcock, 12 of Vermont's Community Hospitals,3 FQHCs
and a number of independent physicians have collaborated
to apply to become an ACO under the CMS SSP. If
approved, this would be operational 1/1/2013.
• An IPA-centric ACO consisting of @ 100 physicians
statewide received designation as a CMS SSP-ACO
beginning July 1, 2012.
In addition, six of the State’s eight Federally Qualified Health
Centers (FQHCs) are organizing a Medicaid and Commercial
SSP-ACO.
These organizations will be invited to participate in state ACO
programs for Medicaid and commercial payers that will be
developed under the SIM grant.
Under this model,
volume-based incentives
are replaced with
episodic-based payments
which encourage
collaboration and
efficiency across
providers and systems.
The model also better
controls growth in
spending by targeting the
top drivers of spending.
Under this model,
volume-based
incentives are
replaced with
incentives for
improving quality
and efficiency of
care.
4. Value Proposition and Performance and Improvement Objectives to be Achieved
We believe these models have the potential to improve health and health care while reducing
costs by: supporting person-centered services and shared decision-making, allowing flexible
use of resources to truly manage and coordinate the care of patients and incentivizing
performance through value-based payment strategies that specifically tie payment to
performance and give providers the potential to share in savings based on the care they
provide. The table below summarizes the unique value proposition and performance objectives
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of each model. The performance objectives and standards for each of the models will be
defined further by the state in collaboration with providers, payers and other stakeholders as
part of this project. Our State Innovation Plan provides more detail on our efforts to date to
develop standards for payment reform models.
Table 4. Value Proposition of the Models
Population-based Performance Coordination-based
Performance
Provider-based Performance
VT Shared Savings ACO Models Bundled Payment Models P4P Models
The SSP models provide a framework for
providers to transition to two sided risk
models by 2016. SSPs also offer a way to
bridge the gap between medical service
providers, behavioral health and
substance abuse providers and providers
of long term services and supports by
incenting cooperation and accountability
through the potential for shared savings
resulting from improved care
coordination, delivery of high quality and
cost effective care, and an increased focus
on prevention and wellness.
Specific objectives include:
• Improve care coordination;
• Reduce utilization of preventable and
unnecessary services
• Improve adherence to clinical
standards
• Integrate EHRs analytics
• Reduce the growth of total cost of
care
• Improve consumer experience
The bundled payment models
complement the other models by
rewarding essential specialty care
providers coordinating with the
PCMHs.
These models have the potential
to have targeted impacts
between providers whose
coordination with primary care
improves quality and reduce
costs for targeted, high return on
investment episodes of care.
Specific objectives include:
• Improve system organization
• Reduce duplication and
maximize system resources
• Improve care coordination
among specialists and
primary care providers
• Improve quality and reduce
long-term costs
• Improve consumer
experience
These programs will
complement shared savings
programs by allowing individual
providers to be rewarded for
their contribution to increased
quality and outcomes for the
people they serve.
By ensuring population and
individual rewards for quality,
the alignment of financial
incentives for each provider is
better balanced.
Specific objectives include:
• Payment increasingly based
on value
• Quality reporting,
measurement and
evaluation of outcomes
improvements
• Improve care delivery and
coordination
• Improve consumer
experience
5. Evidence Basis for Testing the Models
There is growing evidence of the success of patient-centered medical homes and the value of
care coordination and disease management both nationally and in Vermont [1-16]. Over the
past year, findings from the first wave of CMS and CMMI-sponsored demonstration programs
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have provided both evidence of their potential and limitations that must be overcome [3, 5, 10,
17-19]. Vermont will proactively address shortcomings identified in previous pilots and build on
the body of evidence about the potential for these models to transform care and improve
system performance. Evidence in support of these models is summarized below.
Table 5. Evidence Base
Population-based
Performance
Coordination-based Performance Provider-based Performance
VT Shared Savings ACO
Models
Bundled Payment Models P4P Models
Evidence on Accountable
Care Organization (ACO)
shared-savings models
suggests significant potential
for improving quality and
lowering costs. In Medicare’s
Physician Group Practice
Pilot (PGPP) Demonstration
substantial quality gains and
savings were achieved for
some participants; most
savings were found among
dually eligible beneficiaries
[2, 5].
Blue Cross Blue Shield of
Massachusetts’ (BCBSMA)
Alternative Quality Contract
(AQC) employs a global
payment as a strategy for
improving quality and
reducing the annual rate of
growth in health care
spending. Payments are tied
to quality, performance, and
outcome benchmarks over a
five-year period. The AQC
reports lowered costs and
improved quality after year
one.
[2, 3, 5, 10]
A global budget facilitates
clinical and technological
integration and allows for
evidence-based care to be
coordinated across settings
[17, 20-22].
Bundled payments show substantial
promise for delivering savings and
improved quality both as a stand-
alone tool and as a component of a
global budget [23, 24].
A study by the Agency for
Healthcare Research and Quality
(AHRQ) of 20 bundled payment
interventions found that the
introduction of bundled payments
was associated with reductions in
health care spending and
utilization[25].
Bundled payments also have been
proven effective in strengthening
care coordination and quality
measurement[26]. The strength of
bundled payments as a cost
containment and quality
improvement device may be
improved if employed across
providers and care settings to be
consistent with Vermont’s
proposed integrated healthcare
system.
Used in conjunction with shared savings
and bundled payment models, P4P adds a
strong incentive for interdisciplinary
provider teams to coordinate care [27, 28].
A literature review suggests some positive
effects of financial incentives at the
physician, provider group, and health care
payment system levels. Pay-for-
performance programs must be
accompanied by ongoing monitoring and
evaluation to ensure that financial
incentives do not have an adverse effect on
health care quality and access[29]. Vermont
has key evaluation infrastructure for
monitoring P4P already in place, and will
improve upon this infrastructure.
Geisinger Health System ties total physician
compensation to performance incentives
that are defined annually for each type of
clinician. Claims data from a regional health
plan demonstrate that physicians directly
employed by Geisinger have improved
quality and efficiency faster than other
physicians in the same health plan’s
network[30].
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6. Theory of Action
Our theory of action combines public policy levers, public and private leadership and financial
incentives to create cultural and organizational change that measurably affect the three goals
of reduced cost growth, improved population health and improved consumer experience.
Combined these three models will better achieve our desired outcomes than any of them in
isolation or deployed in an uncoordinated manner. Below is a summary of the theory of action
underlying each model.
Table 6. Theory of Action
Population-based Performance Coordination-based
Performance
IProvider-based Performance
VT Shared Savings ACO Models Bundled Payment Models P4P Models
This program will incent the formation of
accountable, integrated provider-led networks of
care which will include qualified providers who
collectively work towards improving quality and
managing rising costs.
The program also prepares these providers to
move over time towards more predictable and
controlled payment models where both payer and
providers share the risk of escalating costs.
This program also complements other financial
models because it focuses on broad population
health improvement across the full continuum of
medical, mental health, substance abuse, and long
term services and supports.
In the long term, having multi-payer shared savings
pools equitably distributed based on the
achievement of both expenditure targets and
quality performance measures will provide
sufficient incentives that will lead to a more fully
integrated person-centered delivery system. As
these networks work to meet both expenditure
targets and quality performance measures, the
result will meet the needs of Vermonters in a
comprehensive, cost effective, and coordinated
way.
Bundled payment models
incent coordination among
primary and specialty care
providers on targeted
high-cost episodes of care.
The payment models
remove volume-based FFS
incentives and replace
them with rewards for
efficiency and quality of
care.
In the long terms, moving
a large proportion of high
cost episodes under a
bundled payment will help
provide payers a
mechanism to better
control costs.
These programs increase the
individual providers’
accountability for the quality
and cost of care.
It also ensures that dollars are
maximized to reward those
systems and providers that
provide the best care and
outcomes for the population
served.
Having P4P models also
ensure that even if an
individual provider does not
share greatly in savings, that
their contribution to better
outcomes is rewards and
continually incented.
.
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These models will be coordinated with the following related state-level payment reform efforts,
as well as federal initiatives (described under #7 below):
• The state’s 1115 waiver renewals;
• A proposed initiative to improve care to individuals dually eligible for Medicare and
Medicaid beginning January 2014; and
• GMCB’s effort to implement global budgets for up to two of the state’s 14 hospitals
beginning in October 2013.
These initiatives are described in greater detail in the State Health Care Innovation Plan.
7. Other Federal Initiatives in the State and Plans for Coordination
Vermont is one of eight states participating in the Centers for Medicare and Medicaid
Innovation’s Multi-payer Advanced Primary Care Practice (MAPCP) demonstration project.
Through the MAPCP demonstration, called the Blueprint for Health in Vermont, Medicare
participates along with Medicaid and commercial payers and provides Vermont’s participating
primary care practices recognized as patient-centered medical homes (PCMHs) with an
enhanced per patient per month (PPPM) payment based on an independently derived NCQA
quality score. In addition, MAPCP shares in the costs of the Blueprint’s Community Health
Teams (CHTs) and provides significant funding for Vermont’s Support and Services at Home
(SASH) program, which provides additional support for high-risk Medicare beneficiaries. The
Blueprint is the foundation for high quality primary care and as such is the underpinning of
proposed health care payment reforms and delivery system innovations in Vermont.
13
Vermont submitted a proposal to the federal government in May 2012 for a demonstration
waiver related to “dually eligible” individuals. Vermont currently manages all Medicaid dollars
associated with the nearly 22,000 dually eligible Vermonters as if it were a managed care
organization under its two 1115 waivers. Under the proposal, the State of Vermont would also
assume responsibility for Medicare dollars. As described in further detail in the Innovation
Plan, the foundation of this duals demonstration relies on the establishment of an integrated
person-directed delivery system based on payment reforms and full integration of care and is in
alignment with the goals of this SIM proposal.
As envisioned, payment reform in the duals project will be achieved through Vermont’s existing
managed Medicaid structure under the Global Commitment to Health Waiver. The state will
receive a prospective blended capitated rate for the full continuum of Medicare and Medicaid
benefits. The goal of the Dual Eligible project is to improve outcomes, enhance quality, and
control costs by providing integrated and person-centered care through integrated care
providers (ICPs). Vermont hopes to enter into a Memorandum of Understanding (MOU) with
CMS during CY 2012, followed by a contract in 2013 and implementation in January 2014. An
important element of the proposal outlined here is development of plans for integrating the
duals project’s payment and service delivery models with the Medicare Shared Savings ACO, to
which some Vermont Medicare beneficiaries already have been attributed and more will be
attributed beginning January 1, 2013. Key questions for Vermont include: will payment models
for ACOs and duals ICPs be integrated or separate?; if separate, how will the state maximize
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continuity of care from the beneficiary perspective?; how will savings be achieved and, if
achieved, shared across the models?
8. Plan for Sustainability of the Models after the Testing Phase
We expect that work under this grant will lead to:
• valid testing of the proposed payment and delivery models;
• capacity-building for providers who operate under a shared savings model to assume
greater financial and performance risk in the future; and
• capacity-building to scale the other payment models (other than shared savings) to a
broader array of services, providers and areas within the state.
Through collaboration with stakeholders and policymakers, models that are successful and
scalable will be incorporated into Vermont health care delivery and financing through changes
in statewide policy through the authority of the GMCB and Medicaid payment policy. The next
stage of health reform implementation also will take into account any mid-course corrections,
additional policy actions necessary (such as provider rate-setting and risk adjustment across
providers) and early experience from the reformed insurance market under the Health Benefit
Exchange.
9. Potential to Replicate the Service Delivery Models in Other States
Vermont’s models are both useful and valuable as a demonstration because the approach is
replicable, scalable, and based on emerging best practices in person-centered care.
Vermont’s proposed model for testing focuses on three specific initiatives that are currently
being tested on smaller scales across the country – the advanced primary care medical home
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model, the shared savings ACO model, and bundled payments that encourage provider
integration for specific patient populations and services. Additionally, development of
oversight for integrated provider networks in the form of ACOs, along with support and
measurement of other value-based purchasing strategies on a statewide basis will provide
other states with an important understanding of the potential of these models.
10. Communities that Will Be the Focus of Model Testing, and Plans for Roll-out
See scope of models described above. All models are intended ultimately to be statewide, but
some of the bundled payment initiatives are more regionally-focused at the outset.
11. Likelihood of Success and Potential Risk Factors
Vermont is confident in the ability of this testing model to proceed. We have to our advantage:
a strong history of collaborative health reform with CMS and within the state; strong state
authority to manage health care costs, quality and resource allocation; considerable provider
community enthusiasm and leadership for payment and delivery reform; multi-payer
participation in reform efforts; experience through CMS waivers with bundled payments for
smaller sub-specialties; and, continued multi-stakeholder involvement in shaping Vermont’s
health reforms.
While we are confident in our ability to succeed, we also are keenly aware of a number of risks
that we have attempted to address through our funding request. Specific risk factors and the
strategy for addressing them are included in Table 7 below.
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Table 7: Potential Risks and Strategies to Address Within the SIM Grant
Potential Risks Strategy to Address/Mitigate
Defining and reporting measurable
results
Vermont will build off its current measures and work to improve its
reporting infrastructure to improve the capacity and sophistication of the
reporting to allow for more robust measurement of the model’s success.
Engagement of high-risk enrollees in
care
To support its testing model, Vermont proposes to utilize SIM funds to
implement a statewide public health campaign focused on the importance
of engagement of individuals in their care; in addition Blueprint CHTs and
extenders will continue to focus efforts on engaging high risk enrollees in
their care.
Attribution and churning In determining how to attribute savings across models, including the SIM
testing model and the State’s Dual Eligibles project, the state will develop
a specified attribution methodology that works in the aggregate to address
appropriate attribution and churn.
Incentive imbalances within the
payment system and across payers
In developing criteria for ACOs, Vermont will include criteria aimed at
requiring balanced incentives with the payment system and across payers
to appropriately compensate providers across the continuum of care for
their role in the management and care of an individual.
Lack of robust evidence for
definitive practices
Vermont will continually review the results of its own work as well as
conduct ongoing literature reviews and interviews with key experts to
keep as up to date as possible on evidence that support best practices.
Need to tailor strategies to specific
populations and program
requirements
While there are advantages to building off existing, proven program
structures and requirements, the special needs of the Medicaid
population, especially those of people requiring long term services and
supports may call for adjustments beyond those already in use by
commercial payers and/or Medicare.
Pressure on AHS/DVHA as state
Medicaid agency given competing
priorities and potential need for
short-term budget savings
The SIM funding will provide much needed staff and consultant support to
AHS/DVHA to accelerate the implementation of the strategies included
within the testing model.
Historical silos across state agencies
that serve single population
Vermont’s 1115 Waivers have provided departments and state agencies
with the opportunity to work collaboratively with regards to budget and
finance plans. Through this grant AHS/DVHA and GMCB will co-chair an
internal group that will serve as a forum to allow for integrated policy
discussions and unified solutions that promote our statewide goal.
The complexity of implementation
and multi-payer coordination as
well as incorporating planned state
insurance exchange plans into
consideration.
The GMCB will continue to work closely and collaboratively with
AHS/DVHA and with the state’s major health insurers to address
implementation and coordination issues. In addition, because DVHA is
responsible for both the SIM grant and the implementation of the
Exchange and GMCB is responsible for payment reform across the state,
they will ensure the alignment and coordination of the plans to be offered
in the Exchange with the SIM testing model.
A concern that providers with a high
Medicaid population who have less
experience integrating all aspects of
healthcare in their coordination
efforts and sharing risk may delay
uptake of reform.
Through the SIM grant, Vermont will provide infrastructure support and
technical assistance to all Medicaid enrolled providers to support robust
care coordination and potentially risk sharing.
Most Medicaid reimbursement The SIM grant will support the move of Medicaid from fee-for-service to
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continues to be based in FFS
methodologies; there is not yet a
comprehensive system which
includes quality as a dimension of
payment.
value-based purchasing strategies by leveraging strategies used and being
developed for Medicare and the commercial market. Additionally,
improved HIT infrastructure will allow greater opportunity for
measurement of quality and outcomes, ultimately tying both to payment.
Strong relationships between
hospitals, acute care, mental health,
substance abuse, and long term
services and supports providers are
not universal.
Vermont will be identifying gaps and possible collaborations among
stakeholders in an ongoing manner and will work with providers in
fostering relationships that can lead to better care and health outcomes
due to collaboration among stakeholders.
Ensuring ongoing stakeholder
support and education for reform.
Vermont will utilize its existing stakeholder groups and advisory boards,
particularly the GMCB and the Medicaid and Exchange Advisory Board to
keep stakeholders informed of the progress in implementing the model
and outreach and education opportunities.
12. Current Clinical Quality and Beneficiary Experience Outcomes and Specific
Improvement Targets
Vermonters receiving coverage through Medicaid and CHIP give the program high marks in
terms of access to care, discussion with personal doctor, and coordination. In the 2011 CAHPS
survey of Vermonters covered by Medicaid:
• 84% reported obtaining urgent care right away; and 88% reported obtaining non-urgent
care within time needed;
• 98% reported receiving information on choice of treatment and 64% reported discussing
prevention of illness with their personal doctor;
• 93% reported that their doctor provided easily understandable explanations, and that
their doctor listened to them; and,
• 82% reported that their personal doctor was up to date on other care received; and 89%
of those receiving care coordination services reported that the care coordinator
provided the help that they needed.
Vermont also tracks its Medicaid and CHIP performance against HEDIS measures. The state
performs near or at the national Medicaid average for well-child visits, and substantially above
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for treatment of asthma and upper respiratory ailments in children, and follow up for children
on ADHD medications. However, Vermont has lower than average performance in terms of
cancer screening rates, diabetes treatment and timeliness of prenatal treatment.
In addition to the specific improvement targets included in Healthy Vermont 2020, the state
will aim to achieve the following improvement targets under this Testing Model:
• Improved access to care in terms of obtaining both urgent and non-urgent care
when needed;
• Improved patient experience with care coordination;
• Improvements in specific clinical process and outcome measures tracked by the
Blueprint for Health including (not limited to):
• Proportion of patients at goal for treatment of chronic conditions for a number of
chronic conditions (e.g. Blood Pressure, Cholesterol, LDL, Hgb A1c, Lung Function)
• Proportion of patients with chronic conditions who have a recorded self-
management goal along with tracking of progress against the goal over time
• Proportion of children with age and gender appropriate assessments as
recommended in Bright Futures
• Proportion of adults with age and gender appropriate assessments and
treatments as recommended in national guidelines
• Adolescent Well-Care Visits, by Age Group
• Well-Child Visits, by Age
• Adults' Access to Preventive/Ambulatory Health Services, by Age Group
• Several measures of cancer screening (breast, cervical, colorectal)
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• Chlamydia Screening in Women, by Age Group
• Diabetes Care – several measures
• Cholesterol Management for Cardiovascular Condition
• Use of Appropriate Medications for People With Asthma, by Age Group
13. Current Population Health Status
Both the Commonwealth Fund and the United Health Foundation most recently ranked
Vermont as the healthiest state.1 Vermont’s strength includes high rates of high school
graduation, high rates of pre-natal care, low rates of violent crime, and low incidence of
infectious disease. Challenges include high rates of binge drinking and moderate rates of
immunization. Despite these generally positive scores, too many individuals residing in Vermont
continue to suffer from conditions that are largely preventable. Vermont’s State Health
Assessment (Healthy Vermonters 2020) describes priority indicators that have been chosen by
public health, health care and human services professionals as important areas of focus for
improving the health of Vermonters over the next decade. Examples of objectives are:
• Increase the % of adults who meet physical activity guidelines from 59 to 65%.
• Reduce coronary health disease deaths from 112 to 99 per 100,000 people.
• Increase the % of adults who receive recommended colorectal cancer screening from 71
to 80%
• Reduce hospitalization for asthma in children under 5 years of age from 18.8 to 14 per
100,000 people.
1 See Commonwealth Fund 2009 Report Card on State by State Status; accessible at
http://www.commonwealthfund.org/Maps-and-Data/State-Data-Center/State-Scorecard.aspx. See also
United Health Foundation’s America’s Health Rankings 2011, accessible at
http://www.americashealthrankings.org/SiteFiles/Statesummary/VT.pdf.
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• Increase the % of children age 19-35 months who receive recommended vaccines from
41% to 80%.
• Reduce the % of 12-17 year olds who binge drink from 11 to 10%.
Based on analysis of the Healthy Vermonters 2020 indicators, three overarching priority areas
for health improvement were identified by public health and external stakeholders and will be
part of Vermont’s 2012-2015 State Health Improvement Plan:
• Reduction of the prevalence of chronic disease through improving physical activity,
nutrition and decreasing the rates of tobacco use;
• Reduction in the prevalence of Vermonters with or at risk of substance abuse and/or
mental illness; and,
• Improvement of childhood immunization rates.
Too many Vermonters, especially younger, less educated, minority and lower income citizens,
experience real differences in years of healthy life when compared to the general population.
These disparities are summarized in table 8.
Table 8. Health Disparities by Income, Vermont, 2010
Disease % adults with income
more than 2.5 times
poverty level
% adults with income
less than 2.5 times
poverty level
Diabetes 4% 8%
Heart Disease & Stroke 5% 11%
Asthma 8% 13%
Obesity 21% 28%
Depression 16% 34%
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14. Waiver Authorities that Exist, and any New Waivers or State Plan Amendments
Necessary
The State is preparing for renewal and extension of its Global Commitment to Health Waiver
and intends to extend its current Medicaid managed care regulatory structures. Under this
structure the state has considerable flexibility to ensure access to care and network adequacy
as well as to utilize various reimbursement strategies not limited to those found in the state
plan. Under this waiver, assuming all covered service obligations are met, the state may use
what would be considered “excess capitated revenue” in a private MCO to invest public funds
in activities that improve the health outcomes of Vermonters. To date, these investments have
included a wide range of approaches to improvement of care including incentive payments to
providers who achieve targeted outcomes and programs that adopt a public health approach.
The state will need to maintain and enhance those authorities to ensure successful CMMI
outcomes envisioned in this proposal. In addition the state will need to work with CMMI to
ensure authorization and access to necessary Medicare data as part of this project.
15. Extent to Which Models Can be Implemented If Waivers or Approvals are Not
Provided
We believe most, if not all, of the innovations we propose can be implemented under Medicaid
and Medicare waiver or demonstration authority previously granted to the state. Broader
Medicare data use authority will be critical to our success in implementing the data integration
platform and analytics described below.
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16. Additional Targeted Improvements Not Described Above
In addition to support for implementation of the models described above, we are seeking grant
support for key investments in “health system infrastructure” within Vermont that cuts across
all the models. We propose six types of targeted improvements in Vermont’s health system
infrastructure (all directed at AIM #4). These are:
• Improved clinical and claims data transmission, integration, analytics and predictive
modeling;
• Expanded measurement of patient experience;
• Improved capacity to measure and address health care workforce needs;
• Targeted efforts to enhance Vermonters’ understanding and active management of
their own health;
• Learning health system activities; and
• Investments in enhanced telemedicine and home-monitoring capabilities.
Each of these initiatives is described in more detail below.
Improved clinical and claims data transmission, integration, analytics and predictive modeling
Vermont has in place four central elements of an integrated health data system:
1. A multi-payer claims dataset (VHCURES) that contains claims from public and private
payers and has been mapped to key measures of utilization, expenditures and quality
tracked by the Blueprint for Health;
2. A statewide health information exchange (VHIE) with capacity to produce care
summaries and continuity of care documents (CCD), lab and other diagnostic reports,
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demographics related to admissions, discharges, and transfers and to query or pull
clinical data from participating providers’ Electronic Health Record (EHR) systems;
3. A “central registry” that captures a defined set of clinical data from Vermont health care
practices;
4. Trainers who work with individual provider sites to develop the data input capacity and
quality controls necessary to produce reliable data sets for analysis and feedback.
These data resources provide a strong foundation to support the data needs of integrated
provider networks as they expand throughout the state. The state is actively working with
payers and providers to expand HIT adoption and HIE connectivity statewide, building on a
seven year base of planning, consensus building, governance refinement, and early
implementation of a standards-based technical architecture. The SIM grant provides the
opportunity to further enhance and integrate these technologies for greater connectivity
among providers, patients, and support services in the community. Specific enhancements
under this project will include:
A. Expanded capacity for transmission of high quality clinical data from EHRs and other
sources to the Vermont Health Information Exchange (VHIE) and the central clinical registry.
Vermont recognizes the critical importance of immediately available and actionable clinical and
claims data that allows providers the opportunity to evaluate their performance and identify
opportunities for improvement using clinical and claims data that is structured, reliable, and
sufficiently complete to support their efforts. Current data capture and quality work is guided
by the Blueprint’s core data dictionary and measure set. Facilitators work with lead clinicians at
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each site to optimize capture of guideline-based elements in EHR (and other) systems as part of
routine care. The SIM grant will be used to enhance and speed up this end-to-end data capture
and quality improvement process; to support mapping of tracking system templates against the
core data dictionary, enhance clinical flow to optimize use of tracking systems; and to provide
increased capacity within the VHIE and central registry. A high-priority focus for this effort will
be assuring efficient and reliable data capture related to quality measures that are embedded
in the testing models proposed in this application.
B. Accelerated development of an integrated data platform to support more advanced
analytics, modeling, and simulations. Vermont’s foundation includes a maturing set of data
sources across an array of domains. These include VHCURES claims data and clinical data from
the VHIE and the centralized registry. There are other data sources that are important to fully
understand health. Vermont is dedicated to bringing data from an array of disparate sources
into an integrated platform to support the most advanced assessments of health, wellness,
quality of services, and costs. Data sources we intend to add include: the hospital discharge
data set, nursing home Minimum Data Set, home health Outcome and Assessment Information
Set, the Social Assistance Management System for long term support and services, the
Developmental Disabilities and Mental Health Monthly Service Report, the Alcohol and Drug
Abuse Programs reporting systems, and Public Health registries and reporting systems, as well
as the expanded scope of clinical data that will be available through expansion of the registry’s
data dictionary and other clinical tracking systems.
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Our plans include implementation of one or more integrated informatics platforms and
establishment of routine methods for complex data management to populate these platforms.
The SIM grant will support: health analytics and informatics platform software and interfaces
necessary to merge clinical, administrative, and claims data; data mapping and normalization
across those source systems for its use in the integrated data platform; secure transmission
networks; and data management and quality assurance within the platform(s). Currently, the
Blueprint, GMCB, and other state users have limited capacity to evaluate outcomes with data
from each discrete source. Vermont would like to enhance data integration, analytic capacity,
and modeling sophistication.
C. Development of predictive models and simulations to guide a learning health system. The
SIM grant also offers the opportunity to contract with top experts in the country to support
advanced analytics and predictive modeling, including health services researchers, health
economists, and actuaries. Given the scope of Vermont’s data sources, and the plan for
integrated data platforms (described above), the goal would be to employ a broad range of
expertise to go beyond traditional boundaries including experts from the social sciences and
other domains that are important to human health and wellness. The results of this work will
include algorithms and models that can be programmed into the reporting platforms that
overlay Vermont’s data sources. It also will include clear methods for generating comparative
groups and adjusted outcomes, methods that will evolve as Vermont gains access to claims
data from outside of the state.
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Expansion of patient experience survey capacity including intensified sampling of targeted
populations and additional content for specific health services interventions. Currently, the
University of Vermont (UVM) evaluation team is an official surveyor for the NCQA PCMH CAHPS
based Patient Experience Survey. They are conducting statewide sampling to evaluate patient
experience in the Blueprint. The SIM grant will be used to intensify targeted sampling to
determine the impact of specific payment and delivery reforms on a person’s experience. This
may include expanded use of mail and internet sampling, and the addition of phone based
sampling. In addition, we intend to add to our data-gathering tools a cutting-edge patient
engagement measurement instrument developed by John Wasson at The Dartmouth Institute.
Improved capacity to measure and address health care workforce needs.
Vermont has been engaged in health care workforce development since the mid 90s when the
first physician licensing survey was implemented. The first health care workforce development
plan was completed in 2004 and took a broad look at over 35 health professions. Common
themes in workforce planning have been assuring a safe, adequate, well distributed health care
workforce, but lack of data – on both supply and demand – is a constant barrier to this work.
We seek to address this critical need through this grant.
A major focus of the activities defined within this proposal concentrate on development of
health care professional surveys for all health professions, as well as collection of demand-side
data related to Vermonters’ access to care. We will employ three specific strategies:
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Strategy #1: Improve workforce planning and monitoring through the collection, analysis and
benchmarking of health care workforce data. Vermont will work with each of the targeted
health professional licensing boards (up to 40) to adapt the national minimum data set
requirements of each specific profession to meet Vermont’s health reform goals. We will
program the minimum data set survey into licensing and registration processes. Each year of
the grant, we will target a new cohort of professions. Also, we will engage consultants to
extract data from the online licensing data set so that it is accurate and meaningful and to
improve metrics and benchmarks of workforce need. The development of these metrics in
conjunction with the analysis of health care workforce licensing data will provide the supply
and demand data necessary to target specific professions and the geographic areas of high
need with strategic recruitment and retention activities.
Strategy #2: Improving workforce depth and strength through job retention services and
training of direct care staff workers. We propose to implement the Personal and Home Care
Aide Training (PHCAST) Program, in collaboration with Department for Children and
Families. The training of personal and home care aides is an essential element in the provision
of quality care to families coping with children and other family members who have mental
illness, disabilities and/or life limiting conditions as well as people choosing to live as
independently as possible who are older or may have a severe mental illness and/or other
disabilities. The PHCAST program would ensure competent personal and home care aides with
acquired skills that would be transportable to any job market in the nation, thus strengthening
the direct care worker workforce.
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Strategy #3: Add to Existing Consumer-Based Data Collection Measures of Access to Care,
Barriers to Care and Gaps in Provider Supply. Vermont conducts a household health insurance
survey by phone on an annual basis. The survey gathers information about household
demographics, health insurance coverage and health care costs. We propose adding to that
survey a rigorous assessment of barriers to care, highlighting any gaps in provider supply from
the demand side. We will design survey questions to allow for comparison with available
benchmarks, such as the Massachusetts Health Insurance Survey, and will assure both an
adequate sample size and appropriate questions to assess barriers to accessing specific types of
professionals, including primary care practitioners, specialists and mental health and substance
abuse practitioners.
Taken together, these initiatives will provide Vermont with a rich source of information to
assess health care workforce needs, improve the supply of LTSS workers and track the impact of
reforms on workforce strength.
Targeted efforts to enhance Vermonters’ understanding and active management of their own
health.
Vermont’s State Health Improvement Plan describes key priorities for reducing the prevalence
of chronic disease among Vermonters including increased physical activity and improved
nutrition, smoking cessation, improved mental health and decreased use of alcohol and drugs.
Through the SIM funding, Vermont proposes two engagement initiatives:
29
1. Vermont’s Health Portal: Vermont proposes to design and implement a web portal (with
links to the Health Benefit Exchange) that will guide consumers to resources that meet their
unique health needs, using a Health Risk Assessment (HRA) as an entry tool. With the explosion
of Internet accessibility, online delivery offers potential for significantly greater reach of
evidence-based health promotion and chronic risk factor management programs for adults.
There is evidence that community wide campaigns that include a combination of HRA, health
education and social supports are effective in increasing physical activity, improving nutrition
and reducing smoking prevalence (CDC Community Guide). Using the results of the HRA to steer
any individual immediately to educational materials and online or community level resources
and social supports (such as Blueprint primary care practices and Community Health Teams)
will promote healthy behaviors that respond to the unique risk factors identified in the HRA.
Local resources would be highlighted including Healthier Living Workshops currently offered
through the Blueprint Community Health Teams, and recreational programs supported by
Department of Health district offices and local health and wellness coalitions.
2. Public engagement in appropriate use of health services: Increasing use of preventive
services and other cost saving and effective clinical interventions depends both on the health
care system’s ability to deliver appropriate services as well as people’s understanding of the
benefits of preventive and other services and their motivation and ability to access services and
make good healthcare decisions. Vermont proposes utilizing SIM funding to develop and
implement a social marketing media campaign that encourages healthcare consumers to
engage in their own health by being more proactive about making appropriate health decisions.
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By promoting preventive services, better information about other medical services and testing,
and shared decision making between patients and their healthcare providers, we will support
the state’s goal of increasing the appropriate use of health care resources among Vermonters.
Resources will include the Choosing Wisely campaign and Shared Decision Making tools that
help physicians, patients and other healthcare stakeholders think and talk about the best use of
health care resources. Vermont will launch two campaigns (television, radio, print and social
media) a year which will include the following: promotion of specific preventive services with a
focus on those services most aligned toward decreasing the most expensive health conditions;
promotion of tools for the public and patients on Choosing Wisely, and promotion of health
care decision tools and other resources for patients and providers.
These efforts will be guided by a work group that involves representatives of provider groups,
payers and consumers, as well as state leaders responsible for development of the Health
Benefit Exchange. The charge of the workgroup will be to coordinate direct-to-consumer
outreach, messaging and diffusion of self-management tools with clinical and insurance market
interventions for consistency and maximum impact.
Learning Health System Activities
Expanded team of skilled facilitators to support transformation and ongoing cycles of
continuous improvement. The Blueprint has established a team of Practice Facilitators to
support primary care practices as they prepare to be scored against the NCQA PCMH standards.
These facilitators also support practices and CHTs with ongoing data-guided improvement. The
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SIM grant will scale this asset as new payment strategies are tested. This will include an
increase in the number of facilitators, as well as the resources and training necessary to assure
a high functioning team. Vermont will work closely with CMMI to assure that the facilitators’
work, training, and methods reinforce the goals of the payment reforms and health services
models that are being tested. Vermont will also continue to work with leaders in the US and
Canada to assure that best practices are adapted as they are identified in AHRQs practice
facilitation demonstration, and from the growing number of facilitator programs in both
countries.
Enhanced shared learning forums at the local, regional, and state level. The Blueprint directly
supports an array of shared learning forums in Vermont. Examples include: Integrated Health
Services Workgroups in each Health Service Area (HSA); regular meetings of Blueprint Project
Managers and Practice Facilitator Teams from each HSA for problem solving and identification
of best practices; and the Blueprint Annual Conference which brings together local and national
leaders. As new payment reforms and service models are tested, it will be necessary to expand
the number and type of shared learning forums at the local, regional, and state level. For
example, a near term plan to add in a structured network for Substance Use and Mental Health,
with supportive payment reforms, will require new learning forums along with comparative
performance reporting to guide ongoing improvement. The SIM grant will provide the
opportunity to establish, test, and refine these forums along with other communication
strategies.
Investments in enhanced telemedicine and home-monitoring capabilities.
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Patient transfers among acute care hospitals can be among the most important transitions for
delivering cost effective care. Transfers that occur and could have been safely avoided are
costly in many ways. Conversely, a patient with complications or potential for deterioration that
is not appropriately transferred for advanced care often end up among the most costly outlier
cases. As part of Vermont’s efforts to develop a more integrated health care delivery system,
we will provide support for piloting telemedicine technology, and propose to implement a
telemedicine transfer consult program to determine medical necessity of inter-facility transfers
among Vermont’s hospitals. In addition, we will pilot implementation of emerging technology
for home telemonitoring for patients with complex chronic disease, and/or high risk of hospital
readmission. We intend to evaluate the impact of more aggressive and dedicated home
monitoring on patient outcomes and cost.
17. Project Processes and Operational Planning
a. Data collection and reporting
In order to evaluate the impact of our proposed reforms, the state anticipates needing the
following data, in addition to that which is available through VHCURES:
1. Medicare enrollment and claims data for Parts A and B including Quarterly 100% VT
beneficiary enrollment files (2007-current); monthly unadjudicated TAP files for MAPCP
attributed beneficiaries (2009- current); annual final action files for 100% of VT
beneficiaries (2007-current). This data includes full eligibility demographic and
geographic data for all VT Medicare beneficiaries.
33
2. Substance Abuse and Mental Health Data for 100% of VT Medicare beneficiaries (2007-
current). Data should capture utilization, charges, and paid claims (final action files) for
Substance Abuse and Mental Health Services.
3. Claims data on populations outside of Vermont to generate comparison groups and
benchmarks. The SIM grant will be used to establish sustainable access to external
sources of claims data and to set up the processes for routine transmission, formatting,
creation of person level records across insurers, and integration of this data into
Vermont’s All-Payer Claims Database.
4. Additional Patient Experience Surveys. Expansion of patient experience survey capacity
including intensified sampling of targeted populations and additional content for
specific health services to determine the impact of specific interventions on patient
experience, as well as patient experience in settings outside the APCP setting (e.g.
mental health, substance use, specialty care, social services, long term services and
supports, home health, public health and community prevention programs).
5. Person-entered data, for real-time clinical use and immediate feedback. Using a
decentralized, internet-based patient-experience measurement tool, we will collect
information directly from patients, in order to assess health status, satisfaction, and to
create action plans designed to improve self-management. Linking this data to clinical
registry will allow for measurements of an individual’s experience of care to be linked to
specific clinical and non-clinical interventions.
b. Provider payment systems
34
Development of provider payment systems to implement all three of the models proposed in
this application will be a major focus of efforts under this grant. We will work with Medicaid
and DVHA’s Management Information System vendor to design and implement new payment
methodologies in conjunction with project leaders. In addition, we will work with private
payers to address the technical and operational needs associated with implementing the
payment models. In both cases, model development, systems testing and implementation will
be supported by both staff and contractors hired under the grant.
c. Model enrollment and assignment processes
Model enrollment and assignment processes will be developed as part of the grant activities.
Enrollment (if any) will vary by model. For example, bundled payment initiatives will focus on
specific clinically-defined patient populations while the shared savings ACO will rely on an
attribution methodology. The Blueprint currently utilizes a claims-derived methodology for
attributing patients to primary care practices. The same methodology is utilized for the
Medicare Shared Savings ACO. Likely we will replicate this methodology for the Medicaid and
commercial SSP-ACOs. The definition of attributed patients for pay-for-performance initiatives
also will vary, driven largely by a specific scope of services and target population. In no case will
beneficiary choice of provider be curtailed.
d. Contracting and administrative processes
Contracting under the project will be overseen by the agencies and departments with lead
responsibility for grant tasks – please see budget and budget narrative. Overall administration
of grant funds and necessary grant reporting will be the responsibility of DVHA.
35
e. Continuous improvement analysis and performance optimization process
Continuous improvement analysis will be a major focus of our data analytics, described both
under infrastructure development above and in section VII of the grant application, relating to
performance reporting and continuous improvement. We are seeking funding for data
collection, data analysis, learning collaboratives and facilitators, all of which will be part of an
infrastructure designed to support continuous improvement.
f. Other processes needed to complete delivery system reform
The other processes necessary to complete the reforms described in this application relate
primarily to development of internal management infrastructure and capabilities within
participating provider organizations. The organizations with whom we will be working to
implement this plan all are new or within a developmental stage. They will require support to
develop the capabilities necessary to implement these reforms, some of which we propose
providing under the grant. In addition, it will be necessary for payers to implement new
payment methodologies within their operations.
g. Project management and governance
This project will be managed jointly by the AHS/Department of Vermont Health Access (DVHA)
and the Green Mountain care Board (GMCB) under a Memorandum of Understanding that
spells out specific roles, responsibilities and accountabilities. Co-leaders of the project will be
the Commissioner of DVHA and the Chair of the GMCB. All aspects of project management will
involve a partnership between the state and major stakeholders in the private sector. Our
overarching goal will be to assure that this project is not “state dictated” but rather project
activities and resources serve all constituencies who should be engaged in developing a high
36
performance health system in Vermont. As such, we will establish a State Innovation Model
Steering Committee that will advise us on all elements of the project. This Steering Committee
will include representatives of all major payers, providers involved in the testing models,
consumers and other key stakeholders.
In addition, we will establish a Steering Committee to assist with development of the data
integration, informatics and analytic platform described in this application, as well as the efforts
to facilitate data transmission and data feedback for a learning health system. Again, this must
be a resource for all involved, and necessitates deep involvement from data “sources” and data
“users.” Additional workgroups will be established to assist with implementation of other
specific project elements and to offer technical input and on-the-ground feedback.
h. Model staffing and roles
Model staffing is described fully in our budget and budget narrative. We are requesting 28 staff
positions, 4.25 at the GMCB and 23.25 at the Agency of Human Services. GMCB staff will be
focused on Medicare and Commercial payer payment reforms, stakeholder coordination and
evaluation, while AHS staff will support an array of Medicaid and CHIP payment reform and
integration activities across six departments. The Chair of the GMCB and the Commissioner of
DVHA will co-lead the project and provide overall direction.
B. Expected Transformation of Major Provider Entities Within the State, Rationale for
their Transformation, and Evidence of their Commitment to Making Specified Changes
37
By integrating a robust model for primary care with specialty care and long-term services and
supports through payment models, data reporting and analytics, the state will promote a
system in which provider organizations are rewarded for better management of service
delivery, better outcomes and better patient experience. If successful, these models have the
potential to be expanded, scaled up and strengthened to complete a dramatic transformation
of health care organizations in Vermont and the relationships between them. Our plan
provides specific financial incentives for providing this high quality care through enhanced pay-
for-performance, bundled payments and shared savings models. As evidenced in their letters of
support, payers and providers in Vermont are committed to aligning their payment strategies in
a manner that ensures consistent expectations for quality performance, and already are
forming new strategic alliances to improve care and reduce cost trends. Both the Blueprint
expansion and the development of ACOs are far more than payment reform strategies. These
efforts can encourage delivery system transformation that is keenly focused on the integration
and coordination of person-centered care. The Blueprint will reach an impressive 80 percent of
Vermonters by October 2013, and will continue to have a tremendous transformative impact
on primary care delivery in Vermont. Likewise, the development of financial incentives that
support individual, group and network-wide collaboration and performance improvement is
likely to have a transformative effect on specialty care (including mental health), hospital care
and long-term services and supports, resulting in a higher-performing, better organized system
of care for all Vermonters.
38
C. Roles of Other Payers and Stakeholders Participating in the Model
The State’s Medicaid Agency, AHS/DVHA, will participate directly in the model testing in
numerous ways: DVHA will directly co-manage the overall project and will provide
administrative management for grant funds; DVHA in partnership with other AHS departments
will use grant funds to develop some Medicaid-specific payment models; and DVHA will
participate in all-payers models that are appropriate for and adaptable to their covered
populations. Private payers will participate in the development of both statewide payment
reform models such as the shared savings programs, and targeted models such as bundled
payments. Their participation, as it is with our current payment reform pilots, will be aimed at
gathering both technical input and ultimately participation in payment changes.
Providers will be involved in the project principally as direct participants in the testing models –
those who choose to participate will be involved in implementation planning, testing and
evaluation. Providers individually and through their professional organizations will be included
in development of the statewide “infrastructure development” described in the grant. Vermont
is fortunate to have engaged stakeholders that share the state’s vision to improve the health of
Vermonters, improve health care outcomes and reduce the cost growth of health care in the
state. All stakeholders have been working diligently for many years on a continued path of
improvement to the state’s health care delivery and payment system. Act 48 mandates “public
participation in the design, implementation, evaluation, and accountability mechanisms of the
health care system.”
39
The state has created internal structures which will be leveraged in the management of the SIM
grant to ensure coordination in health care reform activities among executive branch agencies,
including a health care reform leadership team which is led by the Governor’s Director of
Health Reform and includes the key agency secretaries, departmental commissioners and
deputies, and a health care cabinet that meets quarterly for broader coordination. In addition,
there are additional project-based structures for inter-agency development of policy and
operations related to specific initiatives. In addition, the health reform leadership works closely
with and reports to the general assembly’s Health Care Oversight Committee, a legislative
interim committee charged with overseeing health care reform, and with the Mental Health
Oversight Committee, a legislative interim committee focusing on mental health systems issues,
in particular the replacement of the Vermont State Hospital. The Administration also
collaborates with the Senate Health and Welfare Committee and the House Health Care and
Human Services Committees.
Each state entity working in and responsible for health reform has developed advisory bodies to
ensure its work appropriately engages stakeholders. The GMCB has a General Advisory
Committee, a Payment Reform Advisory Group and two technical advisory groups: the health
care professional technical advisory group and the mental health advisory group. DVHA has six
advisory bodies: the Medicaid and Exchange Advisory Board; the Duals Stakeholder Advisory
Group; and the Blueprint’s Executive Committee, Expansion Design and Evaluation Work Group,
Payment Implementation Work Group, and Provider Practice Work Group. In addition to the
40
formal working groups, the State engages Vermonters in their communities on various health
reform topics through public hearings and other forums.
D. Linkage of the Models to the State’s Health Care Innovation Plan
Vermont’s Health Care Innovation Plan sets as its central goal development of a high
performance health system in the state. That goal is consistent with the State’s Strategic Plan
for Health Reform and with the Triple Aim. This proposal would add financial, technical and
organizational support to a foundational building block for achieving the goal: development of
payment and care delivery models that move away from rewarding volume of service, toward
rewarding better health, better outcomes of care processes and improved quality of life for
Vermonters. We have described in this application and in the Innovation Plan how this effort
relates to other state-level and federal health reform efforts underway in Vermont. We also
have described how the models proposed here will create linkages across physical and mental
health and long-term services and supports. We believe our established state health reform
agenda, along with the statewide and comprehensive nature of our proposed reforms, offer a
unique opportunity to establish the high performing health system we have described.
E. Multi-Stakeholder Commitment
Vermont is fortunate to have engaged stakeholders that share the state’s vision to improve the
health of Vermonters, improve health care outcomes and reduce the cost growth of health care
in the state. All stakeholders have been working diligently for many years on a continued path
of improvement to the state’s health care delivery and payment system. Act 48 mandates
“public participation in the design, implementation, evaluation, and accountability mechanisms
41
of the health care system.” As detailed above and in the State Health Care Innovation Plan,
there are a number of state entities responsible for overseeing, regulating and monitoring the
health care system in Vermont. Each is committed to the successful implementation of these
testing models and to measurably improving the health status of Vermonters while containing
costs, as evidenced by letters of support included from the Agency for Human Services, the
Department of Vermont Health Access, the Green Mountain Care Board, and the Department
of Financial Regulation. Each state entity working in and responsible for health reform has
developed advisory bodies to ensure its work appropriately engages stakeholders. These
advisory boards will play a key role in the state’s efforts to keep stakeholders informed of the
Grant’s progress and to obtain input on implementation and outcomes.
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